Palliative Nurse Practitioner

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Position: Palliative Care Nurse Practitioner, South East New Jersey.

Monogram Health is seeking a full‑time Palliative Care Advanced Practice Provider (APP) to support our rapid nationwide growth. This APP will provide in‑home care for a highly complex patient population, including end‑of‑life patients with CKD/ESRDಾರ, diabetes, COPD, and CHF. The APP will support the Market Physician Executive, the Palliative Care Lead Physician, and an interdisciplinary team to provide palliative care, clinical guidance to patients and their families, including pain and symptom management;

develop appropriate care plans and document advance directives to ensure patient‑centered care.

Palliative Care APPs are quality‑driven clinicians who apply their expertise in a managed‑care, population‑health context. They also engage in population‑health management in a sophisticated, outcomes‑driven manner that promotes palliative care where clinically appropriate and focuses on patient quality of life, education, and shared‑decision making. They will collaborate with our interdisciplinary Pod teams and field clinicians to enhance care integration and optimize palliative care delivery to complex patients through Monogram Health’s comprehensive polychronic care model.

• Collaborate with the Market Physician Executive and clinical leaders including Palliative Care physician to proactively identify patients who qualify for palliative care services andmey & build a patient panel.
• Develop individualized care plans in collaboration with Market Physician Executive and other clinical leaders including Palliative Care physician to ensure patients are placed on appropriate evidence‑based interventions and pathways.
• Provide compassionate, patient‑centric palliative care primarily through in‑home visits, with virtual care as needed, to support outcomes and care in alignment with patient’s goals.
• Evaluate and treat symptoms that may interfere with quality of life, such as pain, pruritus, depression, anxiety, insomnia, etc.
• Collaborate with pharmacists and other clinicians to manage medication panels for complex patients.
• Provide resources and educate patients and their families on the progression of CKD, ESKD, and related conditions, including treatment options and palliative care principles.
• Help families navigate complex medical decisions and improve understanding of prognosis, including advance care planning to discuss values, goals of care, and document patient/family wishes in state AD/POLST forms.
• Deliver evidence‑based, timely care in Thatcher manner that reduces avoidable hospitalizations, maximizes quality of life, and prioritizes patient health and satisfaction.
• Support patients utilizing our interdisciplinary team, including Palliative Care Chaplain.
• Assist with transition to hospice care as appropriate.
• Participate in monthly meetings with clinical leadership to drive Program KPIs and support execution of clinical and financial goals.
• Educate and support team members on palliative care, hospice care, advance directives, symptom assessment, and communication.
• As needed for patient care, conduct assessments, including comprehensive annual wellness exams on patients both in the home and in the virtual environment.
• Counsel and educate patients and families about benefits and programs available to help them live healthier lives.
• Document items such as: appropriate chief complaint, all applicable diagnosis, past medical, family, and social history, review of systems, examinations, medications,ไม่ลดสปีด allergies, assessment, and plan. Complete all documentation and paperwork in a timely manner.
• Coordinate care with primary care providers, specialists, and appropriate ancillary services.
• This position will not be office‑based but will be remote within the state of employment and will need to attend periodic training/meetings outside of that state.
• Prescribe medications, order Fresher tests, and collaborate with patient’s Monogram physician.
• Demonstrate effective performance as reflected by improved patient quality outcomes, which will…